Provider Demographics
NPI:1043435340
Name:COSTA, PETRONILO R (MD)
Entity Type:Individual
Prefix:
First Name:PETRONILO
Middle Name:R
Last Name:COSTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:420 LAKE COOK RD STE 118
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60015-4914
Mailing Address - Country:US
Mailing Address - Phone:847-205-0237
Mailing Address - Fax:866-735-3898
Practice Address - Street 1:420 LAKE COOK RD STE 118
Practice Address - Street 2:
Practice Address - City:DEERFIELD
Practice Address - State:IL
Practice Address - Zip Code:60015-4914
Practice Address - Country:US
Practice Address - Phone:847-205-0237
Practice Address - Fax:866-735-3898
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-13
Last Update Date:2016-10-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036-046-1082083P0011X, 208000000X, 2080A0000X, 2080P0006X, 2080P0008X, 2084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0011XAllopathic & Osteopathic PhysiciansPreventive MedicineUndersea and Hyperbaric Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
No2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral Pediatrics
No2080P0008XAllopathic & Osteopathic PhysiciansPediatricsNeurodevelopmental Disabilities
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILC43728Medicare UPIN